01. Code Blue

1. Stay calm, check your own pulse!

  • Familiarize yourself with the equipment on your ward(s) or hospital.
  • Code huddle each shift: identify specific roles for members of your team (e.g., chest compressions, hand on the pulse, defibrillator control, patient set up (backboard), peripheral/central IV access, etc.).
  • Remember the basics: high-quality CPR, defibrillation, airway management. Don’t worry about being the expert in the room.
  • Use the ACLS algorithm pocket cards. 

2. Always identify yourself as the code leader and stand where people can see and hear you.

  • A good sample introduction is: “I am [your name], I am the code leader. Does the patient have a pulse? No? [Identify someone] start chest compressions.” 

3. Check code status prior to starting ACLS. This may involve assigning someone to check the chart. 

4. Talk out loud through the thinking process and algorithms.

  • Summarize what you know, what has been done, and what is in progress (such as obtaining central access, preparing tPA, etc).
  • Ask if anyone else has any other ideas or suggestions, especially if the patient remains pulseless after several pulse checks.

5. At the start of the code, appoint specific people to specific tasks:

  • Perform chest compressions. 
    • It may be helpful to assign one person to line up individuals for this task.
  • Establish IV/IO access
  • Check pulse.
  • Get the crash cart/defibrillator/backboard.
  • Get ABG, check labs.
  • Nursing (give meds, place leads, etc.).
  • Pharmacist (deliver meds).
  • Get information and chart biopsy.
  • Establish airway (bag mask, intubate).

6. Divide the code into sections

  • Early
    • Introduction, compressions, backboard, monitors, defibrillation, airway, access 
  • Middle
    • Labs, patient information, IV fluids, family notification, bedside ultrasound, CPR quality, summarization, crowd control 
  • Late/ROSC
    • Pressors, new labs, CXR cooling, neurology, ICU, attending notification, code note

7. When applying a monitor leads to the patient, remember: "white to the right, smoke above fire" (white on right shoulder, black on left shoulder and red near precordium on left).

8. If performing chest compressions:

  • Remember to get a backboard under the patient. Use a step stool if needed.
    • Maintain a rate of 100-120 times a minute (rate of the beat of Staying Alive by the BeeGees).
    • Compress between 2 and 2.4 inches.
    • Allow for complete chest recoil. 
  • Minimize interruptions.
  • Rotate chest compressors every two minutes.

9. Defibrillator/monitor:

  • If the patient is in pVT or VF on telemetry, shock immediately. It is okay to pause chest compressions for this. 
  • Always check lead placement and check asystole or a questionable rhythm in 2 leads.
  • When defibrillating with paddles, use 25 lbs. of pressure.
  • Do not shock asystole - confirm that the rhythm is not coarse VF. The “gain” may be increased on the monitor to help differentiate asystole from coarse VF.
  • Resume chest compressions immediately after defibrillation; you will reassess the rhythm during the pulse check in two minutes.

10. Do NOT over ventilate (1 breath every 6 seconds, 10 per minute) as this can lead to increased intrathoracic pressures, decreased venous return to the heart, and decreased cardiac output in spite of adequate chest compressions.

11. Ensure High-quality CPR:

  • Waveform capnography - partial pressure end tidal CO2 <10 mmHg suggests poor CPR quality.
  • Diastolic pressure <20 mm Hg suggests poor CPR quality.

12. Remember the five H's and the five T's for PEA and asystole

  • 5 H's: hypovolemia, hypoxia, hydrogen ion (acidosis), hyper/hypokalemia, hypothermia.
  • 5 T's: toxins (drugs), tamponade, tension PTX, thrombosis (coronary), thrombosis (PE).

13. Debrief after the code. This will allow you to review team performance and identify any areas for improvement, education, or intervention. Call emergency contacts.

14. The next ACLS update is anticipated near the end of 2020.